Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation.

BACKGROUND: Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs remote from term, between 24 and 34 weeks' gestation. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to ensure that the development of serious maternal complications, such as eclampsia (fits) and kidney failure are prevented. Others prefer a more expectant approach, delaying delivery in an attempt to reduce the mortality and morbidity for the child that is associated with being born too early. OBJECTIVES: To evaluate the comparative benefits and risks of a policy of early delivery by induction of labour or by caesarean section, after sufficient time has elapsed to administer corticosteroids, and allow them to take effect; with a policy of delaying delivery (expectant care) for women with severe pre-eclampsia between 24 and 34 weeks' gestation. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 27 November 2017, and reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials comparing the two intervention strategies for women with early onset, severe pre-eclampsia. Trials reported in an abstract were eligible for inclusion, as were cluster-trial designs. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We assessed the quality of the evidence for specified outcomes using the GRADE approach. MAIN RESULTS: We included six trials, with a total of 748 women in this review. All trials included women in whom there was no overriding indication for immediate delivery in the fetal or maternal interest. Half of the trials were at low risk of bias for methods of randomisation and allocation concealment; and four trials were at low risk for selective reporting. For most other domains, risk of bias was unclear. There were insufficient data for reliable conclusions about the comparative effects on most outcomes for the mother. Two studies reported on maternal deaths; neither study reported any deaths (two studies; 320 women; low-quality evidence). It was uncertain whether interventionist care reduced eclampsia (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.06 to 15.58; two studies; 359 women) or pulmonary oedema (RR 0.45, 95% CI 0.07 to 3.00; two studies; 415 women), because the quality of the evidence for these outcomes was very low. Evidence from two studies suggested little or no clear difference between the interventionist and expectant care groups for HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome (RR 1.09, 95% CI 0.62 to 1.91; two studies; 359 women; low-quality evidence). No study reported on stroke. With the addition of data from two studies for this update, there was now evidence to suggest that interventionist care probably made little or no difference to the incidence of caesarean section (average RR 1.01, 95% CI 0.91 to 1.12; six studies; 745 women; Heterogeneity: Tau² = 0.01; I² = 63%).For the baby, there was insufficient evidence to draw reliable conclusions about the effects on perinatal deaths (RR 1.11, 95% CI 0.62 to 1.99; three studies; 343 women; low-quality evidence). Babies whose mothers had been allocated to the interventionist group had more intraventricular haemorrhage (RR 1.94, 95% CI 1.15 to 3.29; two studies; 537 women; moderate-quality evidence), more respiratory distress caused by hyaline membrane disease (RR 2.30, 95% CI 1.39 to 3.81; two studies; 133 women), required more ventilation (RR 1.50, 95% CI 1.11 to 2.02; two studies; 300 women), and were more likely to have a lower gestation at birth (mean difference (MD) -9.91 days, 95% CI -16.37 to -3.45 days; four studies; 425 women; Heterogeneity: Tau² = 31.74; I² = 76%). However, babies whose mothers had been allocated to the interventionist group were no more likely to be admitted to neonatal intensive care (average RR 1.19, 95% CI 0.89 to 1.60; three studies; 400 infants; Heterogeneity: Tau² = 0.05; I² = 84%). Babies born to mothers in the interventionist groups were more likely to have a longer stay in the neonatal intensive care unit (MD 7.38 days, 95% CI -0.45 to 15.20 days; three studies; 400 women; Heterogeneity: Tau² = 40.93, I² = 85%) and were less likely to be small-for-gestational age (RR 0.38, 95% CI 0.24 to 0.61; three studies; 400 women). There were no clear differences between the two strategies for any other outcomes. AUTHORS' CONCLUSIONS: This review suggested that an expectant approach to the management of women with severe early onset pre-eclampsia may be associated with decreased morbidity for the baby. However, this evidence was based on data from only six trials. Further large, high-quality trials are needed to confirm or refute these findings, and establish if this approach is safe for the mother.

Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation.

BACKGROUND: Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs remote from term, between 24 and 34 weeks' gestation. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to ensure that the development of serious maternal complications, such as eclampsia (fits) and kidney failure are prevented. Others prefer a more expectant approach delaying delivery in an attempt to reduce the mortality and morbidity for the child associated with being born too early. OBJECTIVES: The objective of the review was to compare the effects of a policy of interventionist care and early delivery with a policy of expectant care and delayed delivery for women with early onset severe pre-eclampsia. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013). SELECTION CRITERIA: Randomised trials comparing the two intervention strategies for women with early onset severe pre-eclampsia. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. MAIN RESULTS: Four trials, with a total of 425 women are included in this review. Trials were at low risk of bias for methods of randomisation and allocation concealment; high risk for blinding; unclear risk for incomplete outcome data and other bias; and low risk for selective reporting. There are insufficient data for reliable conclusions about the comparative effects on most outcomes for the mother. For the baby, there is insufficient evidence for reliable conclusions about the effects on stillbirth or death after delivery (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.69 to 1.71; four studies; 425 women). Babies whose mothers had been allocated to the interventionist group had more intraventricular haemorrhage (RR 1.82, 95% CI 1.06 to 3.14; one study; 262 women), more hyaline membrane disease (RR 2.30, 95% CI 1.39 to 3.81; two studies; 133 women), require more ventilation (RR 1.50, 95% CI 1.11 to 2.02; two studies; 300 women) and were more likely to have a lower gestation at birth in days (average mean difference (MD) -9.91, 95% CI -16.37 to -3.45; four studies; 425 women), more likely to be admitted to neonatal intensive care (RR 1.35, 95% CI 1.16 to 1.58) and have a longer stay in the neonatal intensive care unit (average MD 11.14 days, 95% CI 1.57 to 20.72 days; two studies; 125 women) than those allocated an expectant policy. Nevertheless, babies allocated to the interventionist policy were less likely to be small-for-gestational age (RR 0.30, 95% CI 0.14 to 0.65; two studies; 125 women). Women who had been allocated to the interventionist group were more likely to have a caesarean section (RR 1.09, 95% CI 1.01 to 1.18; four studies; 425 women) than those allocated an expectant policy. There were no statistically significant differences between the two strategies for any other outcomes. AUTHORS' CONCLUSIONS: This review suggests that an expectant approach to the management of women with severe early onset pre-eclampsia may be associated with decreased morbidity for the baby. However, this evidence is based on data from only four trials. Further large trials are needed to confirm or refute these findings and establish if this approach is safe for the mother.

Características epidemiológicas y clínicas de los pacientes con diagnóstico de enfermedad de membrana hialina, atendidos en el Hospital Nacional Daniel Alcides Carrión año 2012 / Epidemiological and clinical characteristics of patients diagnosed with hyaline membrane disease, attended at the National Hospital Daniel Alcides Carrion 2012

OBJETIVOS: Determinar las características epidemiológicas y clínicas de los pacientes con diagnóstico de enfermedad de membrana hialina del Hospital Nacional Daniel Alcides Carrión en el año 2012. METODOLOGIA: Estudio Observacional, de tipo descriptivo, retrospectivo, transversal. Se trabajó con un total de 83 recién nacidos que fueron atendidos en los servicios de consultorios de neonatología que acuden al Hospital Nacional Daniel Alcides Carrión durante el periodo Enero a Diciembre 2012. Se estimaron las frecuencias absolutas y relativas para las variables cualitativas y medidas de tendencia central y de dispersión para las variables cuantitativas. Se aplicó la prueba estadística chi-cuadrado con un nivel de significancia del 5 por ciento. Para las gráficas de los resultados, se emplearán gráficas de barras y circulares. RESULTADOS: La edad materna promedio fue 26.7±7.6 años, la mayoría entre edades de 15-25 años (48.2 por ciento). El 91.6 por ciento pertenecieron al Callao. Al respecto de los datos obstétricos el 83.1 por ciento no tuvo control prenatal, siendo el número de controles prenatales promedio de 3.9±2.2 veces, el 27.7 por ciento de los recién nacidos nació por parto eutócico y el 72.3 por ciento parto distócico. La presentación del RN más predominante fue Cefálica (78.3 por ciento). El médico Residente atendió la mayor cantidad de partos (86.7 por ciento), el 45.8 por ciento de los RN tuvo edad gestacional entre 29-32 semanas. Los principales factores maternos son la infección de tracto urinario 24.1 por ciento, el parto pretérmino (21.7 por ciento) y el embarazo gemelar (15.7 por ciento). La talla del recién nacido promedio fue 38.4±4.9 cm, el puntaje del Apgar promedio al minuto fue 6.4±2.2 y el peso de ingreso promedio del recién nacido fue 1433±624 gr. El 92.8 por ciento de los recién nacidos tuvo un adecuado peso para la edad gestacional y el 4.8 por ciento fue pequeño para la edad gestacional. El 50.6 por ciento de los recién nacidos tuvo...

OBJECTIVE: To determine the epidemiological and clinical characteristics of patients diagnosed with Hyaline Membrane Disease at National Hospital Daniel Alcides Carrion in 2012. METHODOLOGY: Observational study, descriptive, cross-sectional, retrospective. We worked with a total of 83 newborns that were treated in the neonatal clinic services attending at Hospital Daniel Alcides Carrion National during the period January to December 2012. We estimated absolute and relative frequencies and measures of central tendency and dispersion. We applied the chi-square statistical test with a significance level of 5 per cent. For the graphs of the results, bar charts are used or circular, depending on the variables to correlate. RESULTS: The average maternal age was 26.7±7.6 years, the majority between the ages of 15-25 years (48.2 per cent). The 91.6 per cent belonged to Callao. Regard to obstetric the 83.1 per cent was not data antenatal; the number of antenatal average of 3.9±2.2 times, 27.7 per cent of infants born by vaginal delivery and 72.3 per cent dystocia. The most predominant presentation was cephalic RN (78.3 per cent). The resident physician attended births as many (86.7 per cent), 45.8 per cent of babies had gestational age between 29-32 weeks. The main factors are maternal urinary tract infection (24.1 per cent), preterm delivery (21.7 per cent) and twin pregnancies (15.7 per cent). The average newborn size was 38.4±4.9 cm, the mean Apgar score at minute was 6.4±2.2 and the weight of newborn average income was 1433±624 gr. The 92.8 per cent of infants had a weight appropriate for gestational age and 4.8 per cent were small for gestational age. The 50.6 per cent of infants had a moderate degree of prematurity and 25.3 per cent severe degree of prematurity. The 34.9 per cent of newborns were found between the ranges of 1500 to 2499 gr, and 19.3 per cent between ranges 1000-1249 gr. The 61.4 per cent of newborns were male and 38.6 per cent female...

On the pulmonary toxicity of oxygen. 4. The thyroid arena.

Normally developed thyroid function is critical to the transition from fetal to neonatal life with the onset of independent thermoregulation, the most conspicuous of the many ways in which thyroid secretions act throughout the body. A role for thyroid secretions in growth and maturation of the lungs as part of the preparation for the onset of breathing has been recognized for some time but how this contributes to tissue and cell processes and defenses under the duress of respiratory distress has not been well examined. Extensive archival autopsy material was searched for thyroid and adrenal weights, first by gestational age, and then for changes during the first hours after birth as ratios to body weight. After a gestational age of 22 weeks the fetal thyroid and adrenal glands at autopsy in those with hyaline membrane disease are persistently half the size of those in "normal" infants dying with other disorders. When the thyroid is examined shortly after birth it reveals a post natal loss of mass per body weight of similar orders of magnitude which does not occur in the control group. A clinical sample of premature infants with (12) and without (14) hyaline membrane disease was tested for T(4), TSH, TBG, and total serum protein. The results also demonstrate a special subset with lower birth weights at the same gestational age, and lower serum T(4) and total serum protein. Ventilatory distress in newborn rabbits was induced by bilateral cervical vagotomy at 24 h post natal following earlier injection of thyroxine (T(4)) or thyroid stimulating hormone (TSH) and comparisons were made with untreated animals and by dose. Early life thyroidectomy was performed followed by exposure to either air or 100% oxygen. A final experiment in air was vagotomy after thyroidectomy. Composite analysis of these methods indicates that thyroid factors are both operative and important in the newborn animal with ventilatory distress. This work and the archival data indicate those infants destined to develop hyaline membrane disease through respiratory distress are a distinct developmental and clinical subset with the point of departure from otherwise normal development and maturation in the second or early third trimester. This interval is known to be a period of marked variation in the overview indicators of fetal progress through gestational time. The initiating factor or circumstance which then separates this special subset from normal future development is placed by these observations firmly into the period when human fetal TSH dramatically rises 7-fold (17.5-25.5 weeks) followed by a lesser 3 to 4-fold increase in T(4) which is extended into the early third trimester. The earlier part of this interval is characterized by the thyrotrophic action of chorionic gonadotropin (hCG). The possibility that abnormalities in the intrauterine environment secondary to maternal infection play a role within this time frame is indicated by the demonstration that interleukin-2 (IL-2) induces an anterior pituitary release of TSH. Since IL-2 has this property and is not an acute phase cytokine, some form of chronic infection or an immunopathic process seems more likely as a possible active factor in pathogenesis.

[Neurodevelopment at one year of age [corrected] in preterm newborns with history of maternal chorioamnionitis]. / Neurodesarrollo al año de edad en recién nacidos pretérmino con antecedente de corioamnionitis materna.

BACKGROUND: Recent clinical and epidemiological researches indicate that in preterm infants exposed to chorioamnionitis increases the risk of neurological disorders. OBJECTIVE: To know the neurological development in prematures newborn whose mothers suffered chorioamnionitis during pregnancy and to compare them with newborns without chorioamnionitis. MATERIAL AND METHOD: Is a prospective, comparative, cohort study, which included newborn infants with < 34 weeks of gestacional age and with weight < 1,500 g at birth, born in the Instituto Nacional de Perinatologia from August 1, 2005 to December 31, 2006. Two groups were divided (with and without antecedents of maternal chorioamnionitis), paired by weight and gestacional age, with complete neurological assessment at one year of age with the following instruments: Amiel Tison and Vojta assessment, audiological and prelanguage evaluations. RESULTS: 104 patients were included; 23 belonged to the group with chorioamnionitis, and 81 to the group without chorioamnionitis. With the Amiel Tison assessment at one year of age we found a major alteration risk in active tone of the exposed children to chorioamnionitis (RR: 3.73, CI 95%: 1.05-13.3). The exploration of Vojta at the year of age was abnormal in the children exposed (RR: 1.64, CI 95%: 1.06-2.53). There were no differences in: hearing assessment, prelanguage skills, electroencephalography, visual and auditory evoked potentials of brain steam. CONCLUSIONS: In the exposed group to chorioamnionitis there were a major number of patients (56.5%) with neurological alterations versus the one without chorioamnionitis (29.6%, RR: 1.90, CI 95%: 1.16-3.11). Motor alterations were found with more frequency in this study.

[Risk factors on the occurrence and prognosis of neonatal hyaline membrane disease].

OBJECTIVE: To identify risk factors with related to the occurrence and prognosis of neonatal hyaline membrane disease (HMD) and to develop effective measures to prevent and treat the disease. METHODS: A case control (1 : 4 paired) study was undertaken, with 62 neonates with HMD as a case group paired with 248 sick neonates without HMD and respiratory disorders as a control group. The controls were matched with the cases by admission time (+/- 7 d), birth weight (+/- 200 g) and gestational age (+/- 3 d). All of the patients came from the neonatal intensive care unit (NICU) in the West China Second University Hospital from June 2008 to January 2009. Conditional logistic regression analysis was performed to identify risk factors associated with the development and prognosis of HMD. RESULTS: Fetal distress, placenta previa, preeclampsia, placental abruption, maternal diabetes, and multiple births were identified as risk factors associated with the development of HMD, with an OR 10.459, 9.382, 8.884, 7.817, 7.727, and 7.217, respectively (P < 0.05). The Cochran Armitage trend test showed that the mortality of HMD decreased with the increase of gestational age and birth weight (P < 0.05). The mortality of HMD increased significantly in the patients with complication such as pulmonary hemorrhage, respiratory failure, neonatal asphyxia, and gastrointestinal hemorrhage (P < 0.05). CONCLUSION: Prevention of premature birth and treatment with high risk pregnancy and complications can reduce the mortality of HMD.

[Short-term respiratory outcome of late preterm newborn in a center of level III]. / Devenir respiratoire à court terme d'une population d'enfants nés à 34, 35 et 36 SA dans une maternité de niveau III.

The rate of infants born at 34-36 weeks gestation has increased over the last 10 years. These babies are at higher risk of morbidity and mortality than full-term infants. At present, prenatal steroids are given until 34 weeks. The purpose of this study was to present the epidemiologic data of the late preterm infants and look for respiratory distress risk factors. This is a descriptive, single-center study including 59, 55 and 72 children born at 34, 35 and 36 weeks gestation, respectively, in a level III center in 2005 and 2006 for babies born at 34 weeks and in 2006 for the babies born at 35 and 36 weeks. Of the mothers who delivered at 34 and 35 weeks, 63% and 49%, respectively, had a morbidity. The cesarean-section delivery rate before labor was 36% for the infants born at 34 weeks and 25% for the infants born at 35 weeks. Prenatal steroids were used for 57% of the mothers who delivered at 34 weeks and for 27% of the mothers who delivered at 35 weeks. In the population of the babies born at 34 weeks, a mean delay between the last dose of steroid and delivery was 18.9 days. Of the infants born at 34, 35 and 36 weeks, 27%, 18% and 8% suffered from respiratory distress. The mechanical ventilation rate was 8.5% and 5.5% for the infants born at 34 and 35 weeks' gestation. Surfactant was given to all infants born at 34 weeks who were intubated. Twenty percent of the 34-week-gestation infants and 12.7% of the 35-week-gestation infants required mechanical ventilation or noninvasive continuous positive airway pressure. Respiratory distress was mainly caused by respiratory distress syndrome or transient tachypnea of the newborn. There were no cases of meconium aspiration syndrome. There was 1 case of infection and 2 cases of pneumothorax. One-third of the infants born at 34-35 weeks were admitted to the neonatal intensive care unit. The number dropped to 11% at 36 weeks' gestation. The gestational age was the only significant risk factor for respiratory distress. There was a strong tendency of the respiratory distress rate to decrease in the babies whose mothers had received steroids (odds ratio = 0.39, p = 0.06).

[Preeclampsia increases the risk of hyaline membrane disease in premature infant: a retrospective controlled study]. / La prééclampsie augmente le risque de maladie des membranes hyalines chez le prématuré : étude rétrospective contrôlée.

OBJECTIVES: Relation between preeclampsia (PE) and hyaline membrane disease (HMD) is still controversial. We found interesting to contribute to the study of this relation by comparing a HMD group to a control group with the aim to know if the risk to develop HMD was more important in case of PE. MATERIAL AND METHODS: Two groups of premature infants (HMD group and control group) weighing less than 2000g and hospitalized between 1st January 2004 and 31st December 2005, were compared for data concerning mother (age, parity, diabetes, corticotherapy), PE (severity, complications, type and treatment), delivery (mode, infectious context, perinatal asphyxia) and neonatal stay (gestational age, birth, weight, sex). A multivariate analysis by logistic regression was used to control the effect of potential confounding variables that were considered risk factors for HMD. RESULTS: Ninety-seven neonates were retained and were compared to 97 control. PE was present in 71 cases in HMD group and in 51 cases of control group. This difference was statistically very significant (p=0.003). When we controlled for confounding variables, there was a significant increase in risk to develop HMD (odds ratio, 1.3; 95% confidence interval, 0.7-1.8). CONCLUSION: The risk to develop HMD, in premature infant weighing less than 2000g, is increased in case of PE. These finding support that fetal lung maturity is not accelerated in PE, in the opposite, it is delayed.

[Consequences of premature rupture of the membranes in the perinatal lung]. / Physiopathologie des conséquences respiratoires néonatales de la rupture prématurée des membranes: application à la prise en charge néonatale.

Early premature rapture of the membranes (PROM) during pregnancy is associated with a high risk of perinatal morbidity and mortality. Early PROM impairs lung structures and function through 3 mechanisms : 1) oligo-hydramnios ; 2) fetal inflammatory syndrome ; and 3) prematurity. Thus, the related causes of respiratory failure at birth after PROM are: hyaline membrane disease, persistent pulmonary hypertension induced by impaired endothelial function and/or lung hypoplasia, materno-fetal infection, and bronchopulmonary dysplasia resulting at least in part from the fetal inflammatory syndrome. Severity of the respiratory morbidity is largely unpredictable. Even if gestational age at PROM is considered as a prognostic factor, survival without morbidity exist after PROM as early as 18 weeks GA. Better knowledge of the pathophysiology improved the outcome of the preterm infants born after early PROM. Optimal management of the respiratory failure including minimizing barotrauma is required to prevent from bronchopulmonary dysplasia.

[Antenatal betamethasone during pregnancy with severe diabetes: is better worse than good?]. / Maturation par bêtaméthasone au cours d'une grossesse de femme présentant un diabète compliqué: le mieux est-il l'ennemi du bien?

Diabetic pregnancy is a precarious situation, both for mother and fetus, because it increases the risk of prematurity and respiratory distress. We report 3 cases of severe acute complications following antenatal betamethasone treatment in mothers presenting with severe diabetes. Corticosteroids are strongly recommended to prevent prematurity complications in newborns. We highlight the high risk profile of theses pregnancies, the effect of this treatment on the mother and the child, and question the real benefit of corticotherapy for these fragile newborns. The metabolic and blood pressure balance is dangerously disturbed in such pregnancies by this treatment. This brings the question of how justified are corticosteroids in such cases?

Intrauterine tobacco smoke exposure and hyaline membrane disease amongst triplets.

We assessed the association between prenatal smoking and respiratory distress syndrome (RDS) among triplets using a population-based retrospective cohort of 12,169 triplet live births in the United States between 1995 and 1997. Analysis was conducted using the generalised estimating equation framework to adjust for intra-cluster correlations. A total of 938 cases of RDS were reported comprising 35 among smoking (7.2%) and 903 among non-smoking gravidas (7.7%). The likelihood of RDS was comparable in both smoking categories [adjusted odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.65-1.32]. The risk for RDS due to smoking diminished with declining birth weight albeit non-significantly: low birth weight (OR = 0.99; 95% CI = 0.40-2.42), very low birth weight (OR = 0.85; 95% CI = 0.39-1.86), and extremely low birth weight (OR = 0.69; 95% CI = 0.30-1.58). In conclusion, among triplet neonates, smoking during pregnancy was not associated with respiratory distress syndrome.

[Hyaline membrane disease in full-term neonates]. / Maladie des membranes hyalines chez le nouveau-né à terme.

OBJECTIVES: Evaluation of the consequences of preplanned delivery near term on the neonatal respiratory distress syndrome and its mechanism of occurrence. PATIENTS AND METHODS: During five years, full-term infants (> or =37 weeks gestational age) admitted in the Institut de Puericulture de Paris, with a well characterized hyaline membrane disease, were included in a retrospective study. RESULTS: During this period, 97 full-term neonates with respiratory distress syndrome were hospitalized in the neonatal intensive care unit. The diagnosis of hyaline membrane disease was made in view of clinical and radiological criteria. The study of mode of delivery has shown a high frequency of pre-planned delivery: 54% caesarean and 24% vaginal delivery. A high-risk of occurrence of hyaline membrane disease was identified around 37 weeks gestational age in the case of preplanned delivery. CONCLUSION: Preplanned delivery near 37 weeks gestational age may increase the risk of occurrence of hyaline membrane disease in full-term neonates.

Caesarean route of delivery and hyaline membrane disease: a hospital-based case-control study in Greater Beirut.

A hospital-based case-control study was conducted to examine the relationship between hyaline membrane disease (HMD) and caesarean route of delivery, in light of sociodemographic, obstetric and perinatal confounders and risk modifying factors. The study population consisted of 78 HMD cases and a control group of 803 infants delivered at 25-36 weeks' gestation and admitted over a 16-month period to nine hospitals in Greater Beirut, Lebanon. The likelihood of delivery by caesarean section was nearly twice as high among newborn infants diagnosed with HMD as compared with the non-HMD control group (OR = 2.02, [95% CI 1.04, 3.92], after adjusting for fetal growth ratio, one-minute Apgar score, maternal age, antenatal steroid administration and pregnancy-related complications. The impact of caesarean section on HMD was considerably more important in infants delivered < or = 32 weeks' gestation (OR = 2.10, [95% CI 0.79, 5.52]) as compared with those delivered afterwards (OR = 1.13, [95% CI 0.40, 3.21]).

Respiratory distress syndrome in near-term babies after caesarean section.

OBJECTIVE: Severe respiratory distress syndrome (RDS) caused by surfactant deficiency is described not only in preterm infants but also in (near-) term babies after caesarean section (CS), especially when carried out before the onset of labour. The aim of the present study was to document the severity of this theoretically avoidable entity in order to improve obstetric and perinatal care. PATIENTS: All neonates admitted to the paediatric intensive care unit of the University Hospital of Bern between 1988 and 2000 with RDS on the basis of hyaline membrane disease (HMD) needing mechanical ventilation (MV) after CS and with a birthweight > or = 2500 g were analysed. HMD was diagnosed when respiratory distress and the typical radiological signs were present. Patients were grouped into elective CS before onset of labour and before rupture of membranes (group 1, n = 34) and patients delivered by emergency CS or CS after onset of labour or rupture of membranes (group 2, n = 22). Analysed indices for severity of illness were duration of stay in intensive care unit and MV, ventilation mode, worst oxygenation index (OI), presence of pulmonary air leak, and systemic hypotension. RESULTS: Mean gestational age (GA) was 37 2/7 weeks in group 1 and 36 2/7 weeks in group 2; no patient had a GA of > or = 39 0/7 weeks. Duration of MV was 4.4 days in group 1 and 3.9 days in group 2. Thirteen patients (38%) of group 1 and 7 (32%) of group 2 had to be managed by rescue high-frequency ventilation. A total of 7 patients had an OI>40. Eight patients (24%) in group 1 and 4 (18%) in group 2 developed a pulmonary air leak. Fourteen neonates (41%) in group 1 had to be supported by catecholamines versus 5 (22%) in group 2. There was one death in group 1. CONCLUSION: Severe RDS on the basis of HMD can also occur in near-term babies after CS; even a fatal outcome can not be excluded. The severity of illness in elective CS without labour may be quite high and is comparable to newborns delivered by CS (after onset of labour and/or rupture of the membranes) who were 1 week younger. No case of HMD was found in our population when CS was carried out after completion of 39 post-menstrual weeks of gestation.

Interventionist versus expectant care for severe pre-eclampsia before term.

BACKGROUND: Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs well before term. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to prevent the development of serious maternal complications, such as eclampsia (fits) and kidney failure. Others prefer a more expectant approach in an attempt to delay delivery and, hopefully, reduce the mortality and morbidity for the child associated with being born too early. OBJECTIVES: The objective of the review was to compare the effects of a policy of interventionist care and early delivery with a policy of expectant care and delayed delivery for women with early onset severe pre-eclampsia. SEARCH STRATEGY: We search the register of trials maintained by the Cochrane Pregnancy and Childbirth Group (April 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 2, 2002). SELECTION CRITERIA: Randomised trials comparing the two intervention strategies for women with early onset severe pre-eclampsia. DATA COLLECTION AND ANALYSIS: Trial quality was assessed using the criteria set out in the Cochrane Reviewers' Handbook. Data were extracted and checked independently by both reviewers. MAIN RESULTS: Two trials (133 women) are included in this review. There are insufficient data for reliable conclusions about the comparative effects on outcome for the mother. For the baby, there is insufficient evidence for reliable conclusions about the effects on stillbirth or death after delivery (relative risk (RR) 1.50, 95% confidence interval (CI) 0.42 to 5.41). Babies whose mothers had been allocated to the interventionist group had more hyaline membrane disease (RR 2.3, 95% CI 1.39 to 3.81), more necrotising enterocolitis (RR 5.5, 95% CI 1.04 to 29.56) and were more likely to need admission to neonatal intensive care (RR 1.32, 95% CI 1.13 to 1.55) than those allocated an expectant policy. Nevertheless, babies allocated to the interventionist policy were less likely to be small for gestational age (RR 0.36, 95% CI 0.14 to 0.90). There were no statistically significant differences between the two strategies for any other outcomes. REVIEWER'S CONCLUSIONS: There are insufficient data for any reliable recommendation about which policy of care should be used for women with severe early onset pre-eclampsia. Further large trials are needed.

[Value of prenatal corticotherapy in the prevention of hyaline membrane disease in premature infants. Randomized prospective study]. / Apport de la corticothérapie anténatale dans la prévention de la maladie des membranes hyalines chez le prematuré. Etude prospective randomisée.

OBJECTIVE: The aim of the study was to determine the feasibility, the cost and the effects of antenatal maternal corticosteroid treatment on preventing respiratory distress syndrome in premature neonates of our population. SUBJECTS AND METHODS: Between January, 1, 1998 and June, 31, 1999, 118 pregnant women at 26-34 weeks' gestation and at a high risk of premature delivery, were prospectively randomized in 2 groups: group 1 received intramusculary 24 mg of betamethasone (12 mg every 24 hours), group 2 didn't receive antenatal corticosteroids. At birth, premature neonates were systematically examined by a neonatologist. RESULTS: 131 premature neonates were born (63 from group 1, 68 from group 2). The incidence and the degree of severity of respiratory distress syndrome, appeared substancially reduced (4.8% vs 27.9%) by the use of antenatal corticosteroids. Moreover, neonatal mortality due to respiratory distress syndrome was statistically less in group 1 than in group 2 (22.9% vs 57%). There was no significant difference in the occurrence of maternal or neonatal corticosteroid complications such as infection between treated group and control subjects. We estimated a potential annual savings of 21 thousands tunisian dinars, when the cost implications for antenatal corticosteroid therapy were estimated to 2 thousands tunisian dinars. CONCLUSION: Maternal administration of corticosteroids before preterm delivery results in a decrease in the incidence and severity of respiratory distress syndrome and a decrease in neonatal mortality rate among premature neonates born to treated versus untreated mothers at 26-34 weeks' gestation; added to an annual savings estimated to 21 thousands tunisian dinars.

[Congenital diaphragmatic hernia. II. Is pulmonary hypoplasia an indefinable obstacle?]. / Hernie diaphragmatique congénitale II. L'hypoplasie pulmonaire, obstacle incontournable?

Despite major insights into the pathogenesis and pathophysiology of congenital diaphragmatic hernia, and despite the availability of an antenatal diagnosis and continuous progress in neonatal intensive care, little improvement has been obtained in the prognosis of this malformation. Thus obstetricians, neonatologists and pediatric surgeons are still facing a several dilemma: dilemma before birth to predict the prognosis, i.e., to evaluate the severity of the associated pulmonary hypoplasia in order to decide whether or not to interrupt pregnancy; dilemma after birth in case of severe respiratory failure to decide how far to go in life support. Based on a review of the literature and their own experience, the authors attempt to recapitulate the perinatal management and outcome of this severe malformation.